Jenny McCarthy and the selling of e-cigarettes

I've made no secret of my opinion of Jenny McCarthy. To put it mildly, I don't think that much of her, particularly her flaming stupid when it comes to her promotion of dangerous antivaccine nonsense. To her, vaccines are chock full of "toxins" and all sorts of evil humors that will turn your child autistic in a heartbeat if you let those horrible pediatricians inject them "directly into the bloodstream" and in general "steal" your "real" child away from you the way she thinks vaccines "stole" her son Evan away from her. Indeed, among other "achievements," she's written multiple books about autism in which vaccines feature prominently as a cause, led a march on Washington to "green our vaccines" and has been the president of the antivaccine group Generation Rescue for the last few years. None of this stopped ABC from foolishly hiring her to join the regular cast on The View beginning in a few short weeks.

Because I occasionally check on what Jenny McCarthy is up to, I noticed a couple of weeks ago that she had been hired to be a celebrity spokesperson for blu™ e-cigarettes. Curious, I checked out this video of her hawking the blu™ Starter Pack:

Particularly odd to me is how the ad has Jenny McCarthy hawking blu™ e-cigarettes as a "sexy" way to smoke. She points out dramatically that, now that she is single, being a smoker is a big problem because, apparently, smoking itself is a big turnoff to a lot of men and she hates interrupting dates to have to go outside to catch a smoke. If you believe the commercial, blu™ e-cigarettes have completely revitalized Jenny McCarthy's love life, apparently in the wake of her breakup with Jim Carrey a couple of years ago. Like Matt Carey, I also could not escape the irony of the woman who rails against "toxins" in vaccines and described her struggles trying to stop smoking when she was pregnant now shilling for a device designed to be used to inhale a toxic substance (nicotine) into one's lungs. On the other hand, she has in the past raved about how she absolutely "loves" Botox; so maybe it's not so difficult to understand.

Jenny McCarthy's decision to shill for an e-cigarette company "inspired" me to think that now is a good time to do a post on the evidence base behind e-cigarettes. In particular, I thought it a good time because I have recently been bombarded with huge amounts of e-cigarette spam e-mail, and I've also noticed that a certain organization that represents itself as defending the public against health scares by countering them with science, namely the American Council on Science and Health (ACSH) is very high on e-cigarettes, even going so far as to praise Jenny McCarthy for being on the right side of science for a change, a post that made me want to gag. Unfortunately, I couldn't given that the awesome computer that is Orac is a Plexiglass box of blinking colored lights. A quick search of the ACSH website for e-cigarettes reveals hundreds of posts about them, all uniformly either praising e-cigarettes as the greatest thing since sliced bread for "safer smoking," harm reduction, and an aid to smoking cessation or chastising anyone that has anything bad to say about them or any government entity that seeks to ban or tightly regulate them. Indeed, Gilbert Ross, MD, the executive and medical director at the ACSH, has even written posts for Forbes in which he accuses regulators who would restrict or ban e-cigarettes as being out to kill American smokers, a message echoed on the ACSH's own website, in which apparently European Union regulators share the same homicidal urges towards European smokers that American regulators apparently exhibit towards theirs.

I do so love it when an advocate's rhetoric accuses his enemies of wanting to kill innocent people. Nothing starts my skeptical antennae a'twitchin' faster than that. I can't help but wonder if that advocate is laying down heapin' helpin's of grade-A BS. However, I don't know for sure that that's the case; it might not be. Maybe ACSH is right and e-cigarettes are the most wonderful invention for public health since vaccines. On e-cigarettes, I have been and remain agnostic. After all, it's not implausible to speculate that e-cigarettes might be a useful strategy to assist smokers in quitting as just another nicotine delivery system, nor is it implausible that they could be a safer means of "smoking" than cigarettes. On the other hand, let's face it. E-cigarettes are, without a doubt, drug delivery devices designed to administer nicotine in a vapor, virtually identical in concept to nicotine inhalers already used for smoking cessation, but smaller and looking very much like cigarettes, making them more convenient and socially acceptable for use outside of the home. Yet, as of this writing nicotine inhalers are regulated by the FDA as a drug/device combination, while e-cigarettes are not. As a result, I view e-cigarettes as being in the same category as supplements. This leads to the only question that matters to me in a health issue like this: What does the science show? The disappointing answer: Not a lot one way or the other regarding the two key claims about e-cigarettes: (1) that they're a safe way to "smoke" and (2) that they are a highly effective smoking cessation aid.

E-cigarette facts and history

The effects of tobacco smoking result in enormous morbidity and mortality, through the various cancers caused by smoking, most prominently lung cancer, as well as chronic obstructive pulmonary disease (COPD), and cardiovascular disease resulting in heart attacks, limb loss, and strokes. Consequently, reducing harm from tobacco is a major public health challenge, and smoking cessation would result in an enormous decline in premature death and disability. Indeed, if smoking prevalence were reduced to zero, lung cancer, heart disease, an COPD prevalence would plummet. Various nicotine-delivery systems, such as nicotine patches and nicotine inhalers, have proven to be useful aids to smoking cessation.

E-cigarettes are the most common variant of a class of medical devices known as electronic nicotine delivery systems (ENDS), whose purpose is to vaporize nicotine, along with other substances used to affect the vapor consistency and flavor, and deliver it to the lungs of the user. Indeed, quite a bit of effort goes into making the vapor look like smoke, as can be seen in the video above. Each device typically consists of a tube made of plastic or other material in which there are housed a rechargeable battery, electronic controls, and an electronic vaporization system. Cartridges containing the liquid mixture to be vaporized are attached to the tube, and puffing on the e-cigarette results in the production of vapor, which is inhaled. Frequently, there is a light at the end of the tube that lights up when a puff is taken to simulate the lit end of a cigarette. One notes from Jenny McCarthy's commercial that in the case of blu™ e-cigarettes this light is blue, for reasons that escape me.

The first generation of e-cigarettes as we know them today was developed by a Chinese pharmacist, Hon Lik, in 2003 and patented soon thereafter. They were first introduced into the Chinese market in 2004 and reached the international market by 2006. It didn't take long for a variety of manufacturers to start making them and promoting them as a "healthy alternative" to smoking or as an aid to smoking cessation. In a relatively short period of times, selling e-cigarettes has become big business; it's been estimated that e-cigarette sales could reach $1.7 billion this year. That's still a fraction of the $80 billion a year tobacco industry, but it's a rapidly growing one. Moreover, many e-cigarette companies are owned by tobacco companies, something the ACSH applauds; for example, blu is owned by Lorillard.

According to e-cigarette manufacturers, the vapor inhaled from e-cigarettes does not contain tar or many of the toxic chemicals found in real cigarette smoke. The chemical mixture vaporized is typically composed of nicotine, propylene glycol, and other chemicals. Not all e-cigarettes use propylene glycol as the vaporizing agent (for example, blu e-cigarettes use vegetable glycerin instead), although many do, along with flavors designed to make the vapor more pleasant and attractive, such as menthol, vanilla, cherry, coffee bean, chocolate, apple, and, yes, various kinds of tobacco. This proliferation of flavors has led to concerns that e-cigarettes are attractive to children and could facilitate getting them hooked on nicotine or even serve as a "gateway" to real smoking.

Through a quirk of a ruling based on the 2009 Family Smoking Prevention and Tobacco Control Act,, as long as manufacturers do not make health claims for them the FDA cannot regulate e-cigarettes as drug/device combinations, even though that's what they clearly are. This is why you don't see ads touting e-cigarettes as a smoking cessation aid, but rather as a "healthy alternative" to smoking. Here's what happened. Between 2008 and 2010, the FDA determined that e-cigarettes were unapproved drug/device combinations, but Sottera, Inc., an e-cigarette manufacturer challenged the FDA in court, and the U.S. Court of Appeals for the D. C. Circuit ruled in Sottera, Inc. v. Food & Drug Administration in 2010 that a jurisdictional line should be drawn between "tobacco products" and "drugs," "devices," and combination products. The court further ruled that e-cigarettes and other products made or derived from tobacco can be regulated as "tobacco products" under the act and are not drug/device combinations unless they are marketed for therapeutic purposes. For reasons that are unclear to me, the FDA declined to challenge the ruling, but retains the power under the Tobacco Control Act to add categories to the tobacco products it regulates after going through procedural steps that include a public comment process. As a result, the FDA plans to propose draft regulations for e-cigarettes this fall and put them out for public comment. Until such a time as the FDA finalizes regulations, however, e-cigarettes are unregulated by the FDA, although some states have banned them in public places, much as cigarette smoking is banned in public places in many states. This quirk of U.S. law has been the proverbial camel's nose in the tent that opened the way for the currently booming e-cigarette business.

Are e-cigarettes safer than cigarettes?

Since the main claim being used to sell e-cigarettes right now is that they are safer than tobacco-containing cigarettes, that's the first claim that needs to be examined. If you look at e-cigarette advertising, it's hard not to feel a sense of déjà vu with respect to past tobacco company ads, complete with appeals to "freedom" (Jenny McCarthy's ad uses that, among other common advertising ploys, such as the implication that you'll have more sex if you use this product), celebrity endorsements (McCarthy again), and appeals to sophistication, freedom, equality and individualism. All of this is coupled with, of course, appeals to health, such as this ad for South Beach Smoke:

Indeed, e-cigarette advertising has been characterized as the "Wild, Wild West," something out of Mad Men, and the "next great frontier" for ad agencies. It's not hard to see why. I mean, holy crap. E-cigarette ads are just as blatant as anything I've seen in ads from the 1960s and earlier for cigarettes. I wonder how long it will be before they start showing pictures of doctors to testify how safe they are, the way they did in the 1940s.

As I said earlier, it is not implausible that "vaping" (as inhaling e-cigarette vapor is commonly called) might be safer than tobacco cigarettes. After all, they don't contain the tar and combustion products that cigarette smoke does, although most of them do contain the nicotine. There are nicotine-free e-cigarette cartridges for those who want the experience of smoking but not the nicotine. To me that seems like drinking decaffeinated coffee, something I've never been able to understand, but maybe that's just me. I needs me my caffeine, I'm afraid. Be that as it may, there really is a dearth of evidence one way or the other regarding the safety of e-cigarettes. The evidence that is out there, from my perusal of it, is of almost completely uniformly low quality. Particularly lacking are long-term studies of e-cigarette use, obviously because they've only been on the market for less than a decade and only skyrocketed in popularity beginning around five years ago. For instance, Odum et al pointed out that

Most e-cigarette data on safety and efficacy are derived from the surveys of current or past e-cigarette users.14-18 The surveys have reported successful reduction in smoking and benign side effects, such as dry mouth, throat irritation, dry cough, vertigo, headache, and nausea (Tables 1). Most survey participants were male and from the Unites States, Europe, and Canada. Respondents were typically recruited by posting links on e-cigarette or smoking cessation Web sites and/or sending e-mails with survey links to consumers of ecigarettes. One survey18 recruited subjects by handing out questionnaires at an e-cigarette enthusiast meeting. Many of these surveys14,15,17,18 provided only descriptive analyses to understand the usage patterns and opinions of e-cigarettes along with baseline demographics such as previous quit attempts. One survey16 found a statistically higher amount of throat burning in current smokers versus former smokers and in e-cigarettes with nicotine versus e-cigarettes without nicotine. No differences were found for the side effect of dry mouth/throat.

I perused PubMed for data on e-cigarette safety, and I was appalled at the crappy quality of the studies out there. For instance, here are two more recent surveys compared to the review article I cited above. They tell us little or nothing more. Even surveys reporting adverse events are not particularly helpful. This Internet forum survey, for instance, has a built-in selection bias. Even though it tells us that there are a wide variety of reported effects from e-cigarettes, including cough, headache, panic, nausea, tremor, fatigue, reflux, throat and mouth irritation, burning, dermatitis, and elevated blood pressure, it's hard to tell what the true prevalence of such reported symptoms are. Not surprisingly, given the uncontrolled nature of these studies, they showed that smokers generally liked e-cigarettes, think they help them decrease or quit smoking, and don't cause any significant problems. It's simply amazing how little hard data there are published. Moreover, most of these studies were prone to selection bias because they tended to recruit subjects from visitors to e-cigarette manufacturer websites and e-cigarette enthusiast blogs, and recall bias was certainly a concern given that these studies had no independent verification of smoking cessation. In other words, these surveys are pretty much useless.

In 2009, the FDA was concerned about the content of e-cigarettes and undertook an analysis of two leading brands of e-cigarette cartridges and found that one out of the 18 cartridges contained 1% diethylene glycol, an ingredient in antifreeze that is toxic to humans. Also noted were "certain tobacco-specific nitrosamines which are human carcinogens" in half the samples tested. Other findings included:

Tobacco-specific impurities suspected of being harmful to humans—anabasine, myosmine, and β-nicotyrine—were detected in a majority of the samples tested.

The electronic cigarette cartridges that were labeled as containing no nicotine had low levels of nicotine present in all cartridges tested, except one.

Three different electronic cigarette cartridges with the same label were tested and each cartridge emitted a markedly different amount of nicotine with each puff. The nicotine levels per puff ranged from 26.8 to 43.2 mcg nicotine/100 mL puff.

One high-nicotine cartridge delivered twice as much nicotine to users when the vapor from that electronic cigarette brand was inhaled than was delivered by a sample of the nicotine inhalation product (used as a control) approved by FDA for use as a smoking cessation aid.

These findings have been disputed. For instance, it has been pointed out that the tobacco-specific nitrosamines found by the FDA are present in e-cigarette vapor are present at much lower concentrations than in cigarette smoke and comparable to what is found in nicotine patches. Given that the only chemicals found in e-cigarettes that raise significant health concerns are tobacco-specific nitrosamines and diethylene glycol (believed to be a contaminant from the use of non-pharmaceutical grade polyethylene glycol), from the standpoint of the vapor, e-cigarettes probably are safer than regular cigarettes. A recent technical report from Igor Burstyn of Drexel University reports that the levels of contaminants e-cigarette users are exposed to are "insignificant, far below levels that would pose any health risk." However, although it's referred to in various places as a "study," it really isn't. It's a review article, and it wasn't even a peer-reviewed article, simply a "technical report" posted at the Drexel website and touted by press release. It was also funded by Consumer Advocates for Smoke-free Alternatives (CASAA), a group that promotes “reduced-risk” alternatives to cigarette smoking, including e-cigarettes. To be honest, given the funding source of this review and its lack of publication in a peer-review journal — one blog comment hilariously states that the study "has been made public for peer review. As CASAA promised when fundraising, the researcher would not keep the study results a secret from the public during the review process" — I'm less than impressed, for obvious reasons. And for shame, ACSH, for promoting this piece of propaganda! If you think I'm being too hard on ACSH, then just imagine what its reaction would be if a supplement company pulled this sort of stunt, publishing a "technical report" that's not peer-reviewed and promoting it. Or if someone who doesn't share its sterling view of e-cigarettes tried it.

Otherstudies have evaluated the effects of e-cigarette use on various measurable endpoints, such as plasma nicotine levels, heart rate, and expired carbon monoxide concentrations, but these were all short term studies using surrogate endpoints. Another study comparing tobacco cigarettes and e-cigarettes found that e-cigarette vapors produced smaller changes in lung function than tobacco smoke, but resulted in similar levels of nicotine in the blood as measured by the metabolite cotinine, while another study supports the observation of at least some adverse physiologic changes due to e-cigarette vapor. Specifically, use of an e-cigarette for 5 min was found to cause an increase in impedance, peripheral airway flow resistance, and oxidative stress among healthy smokers. On the other hand, this increase was small, and it is unclear what its clinical significance may be.

Given that e-cigarettes are too new for long-term studies to have been done, harm from the vapor can’t be ruled out, but it’s not unreasonable to provisionally conclude that it probably is less than tobacco smoke. The problem is that that’s a really low bar to clear, given how incredibly harmful tobacco-containing cigarettes are known to be, and says nothing about whether e-cigarettes are acceptably safe. The other problem, of course, is that that rigorous, well-conducted, long-term studies on e-cigarette safety are basically nonexistent. All we can do is extrapolate from surveys, chemical analyses, and generally low-quality data, and there’s a lot of uncertainty in doing so.

Are e-cigarettes effective smoking cessation aids?

The vapor is not the only issue with respect to e-cigarettes, though. They are, after all, intended as nicotine delivery devices, oddities in the law here in the US notwithstanding that classify them as tobacco products even though they contain no tobacco. Although manufacturers are not allowed to make the claim that e-cigarettes are useful smoking cessation aids, promoters of e-cigarettes as a harm reduction strategy, like the ACSH, are not nearly so shy about trumpeting such claims far and wide, even to the point of claiming that attempts to ban or strictly regulate e-cigarettes will "kill smokers," presumably by robbing them of their one and only chance to quit smoking. It's massive hyperbole, of course, because data are so lacking, and these are the claims that set my skeptical antennae a'twitchin'.

So what about nicotine? One concern the FDA reported was a highly variable nicotine delivery rate per puff from cartridge to cartridge of the same brand. (One notes at least one other study citing variable nicotine content in e-cigarette cartridges.) That suggests poor manufacturing processes and lack of standardization that are concerning. In addition, e-cigarettes appear to deliver less nicotine compared to FDA-approved nicotine inhalers, as measured by peak plasma concentrations after 10 puffs. According to manufacturers, these cartridges generally contain between 6 and 26 mg of nicotine, although there are cartridges on sale that contain as much as 45 mg of nicotine. In comparison, a typical cigarette generally delivers approximately 1 to 3 mg of absorbed nicotine. However, e-cigarette cartridges are not meant to be the equivalent of one cigarette; so a one-to-one comparison is difficult, as a typical cartridge is the equivalent of up to a pack of cigarettes, as many as 350 puffs.

When I perused PubMed looking for studies on the efficacy of e-cigarettes as a smoking cessation aid, I was no longer surprised to note an extreme paucity of them. There are to date no randomized double-blind controlled trials. Zero. Zip. Nada. In fact, I could find only two studies that weren't in my opinion such dreck that they weren't worth bothering to mention, and the larger and better designed of the two was essentially negative. First, there was a randomized, single-blind study by New Zealand researchers with a cross-over design in which subjects who smoked more than 10 cigarettes a day for at least one year who weren't trying to quit used either a nicotine inhaler, a no-nicotine e-cigarette, a 16 mg nicotine e-cigarette, or their own cigarettes for a nine hour period. The results? The 16 mg e-cigarette and the nicotine inhaler produces a similar reduction in the desire to smoke compared to the no-nicotine e-cigarette. It was a small study, of course, and only looked at short-term surrogate outcomes. As such, it says little about the use of e-cigarettes as a smoking cessation aid other than that they might be useful.

More recently, there was a larger study of a similar design from an Italian group published in PLoS ONE. It was larger study (300 smokers) looking at three different strengths of a popular e-cigarette in Italy. Group A (n = 100) received 7.2 mg nicotine cartridges for 12 weeks; Group B (n = 100), a 6-week 7.2 mg nicotine cartridges followed by a further 6-week 5.4 mg nicotine cartridges; Group C (n = 100) received no-nicotine cartridges for 12 weeks. Subjects underwent nine visits during which cigarette use and exhaled carbon monoxide levels were measured. Interestingly, declines in cigarettes/day use and eCO levels were observed at each study visit in all three groups with no clear consistent differences between study groups in rates of smoking cessation and declines in cigarette use. There was no difference in adverse events, either, including dry cough, mouth irritation, shortness of breath, throat irritation, and headache. In other words, it was a negative study, but that's not how it was spun. Not surprisingly, the authors argued that e-cigarettes are useful adjuncts to smoking cessation.

My interpretation? There was no real control group, and this study suggests that it doesn't matter whether there is nicotine in the e-cigarette or not. Moreover, there's no way of knowing whether there was selection bias, and 40% of subjects didn't show up for their last visit. From my perspective, the Hawthorne effect, in which the simple process of observation results in improvement in behavioral studies regardless of the intervention tested, could potentially account for this result. That's why appropriate control groups are so essential. (I bet that if there were a no-intervention "observation only" group and a nicotine patch control group, there would have been a significant decline in smoking in those groups as well.) Sadly, the authors didn't even mention that possibility.

As I said before, the question of whether e-cigarettes are a useful smoking cessation aid is a question that cries out for a decent randomized, double-blind controlled trial and a trial comparing them to conventional methods currently used for smoking cessation. As anyone who's ever smoked or dealt with smokers know, smoking cessation is an incredibly difficult nut to crack. Even the treatments that work don't work all that well. As far as e-cigarettes go, the best I could find was a proposed protocol from investigators in New Zealand for a randomized double-blind, placebo-controlled trial:

Design: Parallel group, 3-arm, randomised controlled trial. Participants: People aged ≥18 years resident in Auckland, New Zealand (NZ) who want to quit smoking. Intervention: Stratified blocked randomisation to allocate participants to either Elusion™ e-cigarettes with nicotine cartridges (16 mg) or with placebo cartridges (i.e. no nicotine), or to nicotine patch (21 mg) alone. Participants randomised to the e-cigarette groups will be told to use them ad libitum for one week before and 12 weeks after quit day, while participants randomised to patches will be told to use them daily for the same period. All participants will be offered behavioural support to quit from the NZ Quitline. Primary outcome: Biochemically verified (exhaled carbon monoxide) continuous abstinence at six months after quit day. Sample size: 657 people (292 in both the nicotine e-cigarette and nicotine patch groups and 73 in the placebo e-cigarettes group) will provide 80% power at p = 0.05 to detect an absolute difference of 10% in abstinence between the nicotine e-cigarette and nicotine patch groups, and 15% between the nicotine and placebo e-cigarette groups.

Which is what is desperately needed, a head-to-head comparison between e-cigarettes with nicotine, without nicotine, and nicotine patch alone. I hope these investigators succeed in getting this trial going and that it produces clearly interpretable data. This is a question that needs to be answered. Badly.

The bottom line

E-cigarettes started out as a promising idea that turned into a product that got away "into the wild," so to speak, before being adequately studied. Originally conceived as a safer way for a smoker to get is nicotine fix, e-cigarettes have evolved into a fad driven by claims that they are much safer and promoted by e-cigarette companies and now by the big tobacco companies that are frantically buying up e-cigarette companies and/or introducing their own brands. Because, through a quirk in US regulatory law, they are currently unregulated, which has led to a proliferation of many, many brands of variable design and reliability. Although short term studies of e-cigarettes appear not to have found any evidence of significant harms, there are currently no solid long term data regarding the effects of inhaling the vapors produced by e-cigarettes. A recent review concluded that the vapors are likely safe, but did so based on primarily on a review of chemical analyses of e-cigarette vapor. A more recent analysis finds some toxic chemicals in e-cigarette vapor butat much lower levels than in tobacco smoke. Again, however, there are no long term epidemiological or observational data in actual humans using e-cigarettes.

Given that e-cigarettes are being touted as a replacement for smoking and thus presumably for long term use rather than short term use as a tool to quit smoking, this is a rather glaring problem. Moreover, we don't know yet whether long term use of nicotine delivered in this manner is safe. Nicotine is, after all, an addictive drug whose use results in vasoconstriction, increasing heart rate and blood pressure, as well as inducing a combination of free radical production, vascular wall adhesion, and a reduction of fibrinolytic activity in the plasma that might be an indication of contributing to atherosclerosis. It might be safe delivered this way. It might not. We don't know.

Despite all the uncertainty, on the one side we see anti-tobacco activists proclaiming e-cigarettes to be potentially harmful and gateway drugs to children leading to the use of real tobacco, while on the other side we see e-cigarette promoters (and I do count ACSH among that group) making concreted, absolutist statements that e-cigarettes are safe and effective aids to smoking cessation. The evidence base is such that both are overstating their cases, although I tend to conclude that the e-cigarette apologists are overstating their case more, given the apocalyptic rhetoric of regulators killing smokers. The hypocrisy of some of the rhetoric is astounding, attacking apologists for unregulated supplements for promoting them, while simultaneously blasting critics of unregulated e-cigarettes! Meanwhile harm reduction seem to have no qualms about citingtestimonialsselectionbias-laden surveys as "evidence" that e-cigarettes definitely help smokers quit. Quite frankly, I don't get it. Would the same people accept such low quality evidence in support of, say, supplements? Or claims that e-cigarettes are a "gateway" to tobacco smoking? Surveys routinely show that people love their supplements and believe them to improve their health. Accepting such low quality evidence for the efficacy of e-cigarettes in the same thing as accepting surveys data as evidence for the efficacy of supplements, and it distresses me how many are either unable or unwilling to understand that.

I can understand provisionally concluding that e-cigarettes are safer than cigarettes (they likely are), but the evidence that e-cigarettes are an effective aid to smoking cessation is currently slim to non-existent, much less any evidence that they are more effective than nicotine patches or inhalers, as is sometimes claimed. Making definitive statements about the safety or efficacy of e-cigarettes is not an evidence-based stance. An evidence-based stance towards the question of whether e-cigarettes are an effective smoking cessation aid is, "We don't know yet. Rigorous studies are desperately needed." At least, that's my story, and I'm sticking to it. As I said early on in this post, when it comes to e-cigarettes, I have been and remain agnostic, particularly in light of the massive advertising and promotional campaigns designed to sell them. To me, today, that is the correct science- and evidence-based stance. Show me some decent evidence, and I will change that stance. In other words, put up or shut up.

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What gets me about e-cigs is there is absolutely no indication of their strength, no indication of their ingredients, no regulation of their sale or advertising. It's fairly obvious that they're being sold and advertised to everyone, not just existing smokers.

Now perhaps on balance an e-cig is better than a cigarette (less toxins, carcinogens, second hand smoke etc.), but at the same time the way e-cigs are being sold is just wrong.

Most countries have strict regulation of cigarettes and even of products like nicotine patches and gum. I don't see any reason that e-cigs should be exempt from similar regulation. I wouldn't be surprised if governments are in various stages of preparation to clamp down on sales, but it's still intolerable.

As for Jenny McCarthy, well... who really expects anything better of her. I wonder why she blames vaccines for autism when smoking during pregnancy is known to cause birth defects.

I'd be interested in an analysis of the secondary smoke effects. I'm a non-smoker and I particularly loathe cigarette smoke (to the extent that I avoid 95% of local night life), so if all smokers switched to e-cigarettes overnight I'd be overjoyed.

I've sat right next to a friend smoking one of them and all I smelled was the extremely mild scent of the water vapour -- I got something similar from sitting near people smoking a hookah.

The lack of a repulsive and lingering stench is pretty much good enough for me -- I'm not too worried about the actual chemical content of the vapour. But it would be nice to know what it is.

I have a question: The health risks of smoking during pregnancy are well known. Have the effects of nicotine replacement therapy during pregnancy ever been studied? E.g. the effect on birth weight of chewing nicotine gum throughout pregnancy.

Propylene glycol? So McCarthy is selling a chemical which in an earlier career she singled out as a Really Evil Thing, so potent an autismogen that its presence as a trace ingredient in vaccines was enough to discredit the whole idea of vaccination? But it's OK in vaporisers if she's being paid to promote it?
HA HA HA.

The best thing about e-cigarettes is that they bother non-smokers like me much less than normal cigarettes do. Goodbye horrible stench and having to interrupt important meetings and work sessions for frequent tobacco breaks. That is more than enough reason to praise them.

I see teens using these more and more if I go out at night or to the mall. I'm hoping someone tracking cigarette smoking will work on a few survey questions to see if teens started with these first.

As Alex mentioned above, there aren't the unpleasant fumes from ecigs that come from a conventional cigarette, but given that FENO went down in smokers who tried ecigs, I do have concerns that even if the exhaled vapor doesn't have all the noxious smells and ingredients of tobacco smoke, it still could be a "secondhand vapor" risk for people with asthma, as it's clear people are using them in very confined place where tobacco smoke would not be tolerated, such as on a plane flight (http://www.electroniccigarettereview.com/smoking-on-planes/).

JM will still need botox for those "smoker's wrinkles" that you will get from an ecig. I guess botox is ok to go in her body, too, even if it is for purely cosmetic purposes (sorry, but while botox has some very important non-cosmetic medical indications (such as muscle tightness in cerebral palsy), I disagree with its use for wrinkle control).

I wonder if ecigs violate any of the oh-so-well-tested advice JM's son's pediatrician wrote in his "landmark" book on "preventing autism".

E-cigarettes are no more an aid to smoking cessation than methadone is an aid to opiate abstinence.

A friend of mine attended a society wedding last weekend, and told me she was shocked at how many people were smoking e-cigarettes, and that those she spoke to said they had no intention of quitting. I can see it as a form of harm reduction, but I suspect that for many people it is is an obstacle to simply quitting nicotine altogether.

Unlike other drugs of abuse, nicotine doesn't even make naive users feel good, quite the opposite, so why so many of us manage to keep taking it long enough to get addicted has long baffled me.

I believe there is some evidence that nicotine can reduce the risk of Parkinson's, but that's about the only positive thing I have read about it. I don't think it is enough to outweigh the adverse cardiovascular effects.

By the way, should anyone consider the effects of nicotine trivial, I'm reminded of an old colleague of mine, a non-smoker, who was on a long flight and noticed the man in the seat next to him getting free chewing gum from the stewardess. Not realizing it was nicotine gum provided free by the airline for habituated smokers, he asked for some and the stewardess obliged.

His resulting reaction led to the pilot radioing ahead to get an ambulance in attendance on landing. This was embarrassing for my colleague when the medics figured out he had simply poisoned himself with nicotine.

I've used an e-cigarette to quit. Recently, actually. I've gone almost a week now without a puff at all and three weeks since my last real cigarette.

What I found useful was the ability to drop the habit portion of smoking, not just the nicotine. I've quit smoking previously (successfully, kinda. A long, weird string of events got me back into the habit over a year later). What I wanted/craved was that forced "break" that smoking gave me. A reason to walk outside and walk away from everyone and everything. I could always go a few days and suck up the lack of nicotine, but the want of just stepping outside and doing something with my hands lured me back. I really did want to quit. My husband did some research on e-cigs and thought it'd be at least worth it to try.

So, for about a week, I'd just step outside with my e-cig. Slowly, but surely, I broke that habit. What helped was that I could reduce. You see, with regular cigarettes, I'd feel guilty about "wasting" them if I didn't smoke a full one. With the e-cig, I could just puff once or twice, clear my head, and resume with life. Within a week, I was only "going outside" twice a day. The last time I used my e-cig was a few days ago.

Of course, I also know of a few people who got an e-cig and went from heavy smokers to pretty much chain smoking. Personally, I think it has a lot to do with if the person really wants to quit or just wants a cheaper/"safer" way to smoke. Of course, this is all anecdote and I'd love to see the science behind it, but it's my story and I'm extremely proud of quitting.

His resulting reaction led to the pilot radioing ahead to get an ambulance in attendance on landing. This was embarrassing for my colleague when the medics figured out he had simply poisoned himself with nicotine.

Wasn't there a quitting method for smoking where you basically were made to smoke until you got ill (presumably either from the nicotine or carbon monoxide), which was basically aversion therapy? Hopefully you were medically monitored if inducing nicotine poisoning was part of the protocol.

about the dirty little secret she has**.
Notice her dress and her posing: Jenny is saying, " See how thin I am!" Many women ( and most likely, some men) use smoking as a way to manage appetite and control their weight. This makes smoking ( of cigarettes and e-cigarettes) quite attractive to very young women ( teenagers) who are underdoing a rapid change in appearance and fear the pounds.

Many role models for appearance ( models, actresses, singers in pop culture) use smoking to maintain extremely low weights that are rewarded by social approval and being paid to look a particular way. Smoking is often mentioned when they are interviewed by fashionable magazines. Jenny is amongst this cohort.

Every now and then, when passing a group of young, attractive women smoking outside, a guy might remark that it's a shame that they're so attractive AND smoke. I always point out that smoking is a way to creating their look.

If you scan drug stores and vitamin stores, you'll discover a corncucopia of products to battle weight gain and eating normally:
e-cigarettes fit right in

Anecdotal story.
My local bar has many smokers but no smoking inside. For about 2 months, we had 3 or 4 people who were smoking the e-cigarettes. There was no cigarette smell and the visible vapor dissipated quickly, so it didn't bother me. In conversation, none of the e-smokers were dedicated to cessation, just trying to "cut down a little". After about 2 months, no-one was using e-cigarettes anymore.
Moral - who knows, but I'd like to hear others' anecdotes.

#12 Chris Hickie:
I went thru a cessation program once. At the beginning, all participants had to turn in their pack of cigarettes (the first night we were allowed to smoke). They took the cigarettes and treated each on with something to make the ends taste bitter. Then each night, we had to pick a random cigarette out of a bag and furiously puff on it (no inhaling, ha, ha) while they flashed a slide show of ugly pictures of people with cancer.
The program was guaranteed to work - you could come back and repeat at any time. The funny (sad) thing is they claimed the program did not use aversion therapy.

Sometimes I like to drink coffee as something to do with my hands or as a companion on a long drive, not for a fix, so I'll drink decaf.
If the last decaf coffee you had was instant Sanka, you might be pleasantly surprised.

next door, I have two gay men ( ages: approx 25 and 35) who would each come unti the balcony to smoke ( real cigarettes, occasionally, other substances).

Now I notice that the older one doesn't smoke there anymore but every now and then, I see him walking around near the cars with an e-cigarette ( not blu) whilst the younger continues on schedule. Neither is ridiculously thin.

My interpretation? There was no real control group, and this study suggests that it doesn’t matter whether there is nicotine in the e-cigarette or not.

Which is not surprising. Smoking is a nasty habit to quit, because not only are you fighting the chemical dependence, but you are also battling the physical addiction, which I contend is even stronger. If it were just about nicotine, then alternate delivery methods (patches, gum) would suffice. However, the act of smoking itself is also addictive, and in the realm of something like cracking your knuckles or biting your nails (or, to an extreme, gambling).

If the last decaf coffee you had was instant Sanka, you might be pleasantly surprised.

Every decaf I've tried has been utterly insipid. I know that caffeine isn't the only bitter compound in roasted beans, but its absence definitely affects the flavor profile in my case.

As for the electronic cigarettes, I have a friend who gave them a several-month run recently before switching back to Marlboro Lights Gold Pack.* I could very clearly detect a tobacco odor from the exhaled vapor.

Adam@1 - The e-cigs on sale over here, at least the reusable ones, are labelled according to their strength. The brand that my wife uses has (IIRC) 20mg/16mg/11mg/6mg cartridges and a nicotine-free type. The site also breaks down the equivalent cigarettes per cartridge.

@Denice - I'd wondered about the subliminal associations between "sexy" and thinness. Fortunately there are no similar ads over here that I've seen, or I'd probably blow out my last sanity lobe!

WRT e-cigs in general, Other Mrs elburto uses them. She stopped smoking in January 2007 with the aid of nicotine lozenges, and didn't smoke again until last year, when I went from being disabled but independent (able to get around our house, take care of my own hygiene and bodily functions, get my own food etc.) to bedbound, practically overnight. I went into hospital ill but mobile, and my feet haven't touched the ground since then*. Then her dad was told he was to be made homeless because gov't cuts forced the council to close his sheltered housing complex, and during this period he appeared to come down with a cold. Friday he was snuffly, Sunday he was cyanotic and taken to hospital and he never left. After one night in a medical ward he was so ill that he was taken to ICU for 2-1 nursing, and two weeks later he was dead, and OME became an orphan at the age of 40.

She'd been visiting him, working, and taking care of my every need, so I suppose a return to smoking was inevitable. I managed to wring the truth out of her after one too many excuses about why she reeked of smoke. Not only am I allergic to the actual smoke (yay, asthma!) but the smell of stale smoke makes me literally puke. So she tried lozenges again, and munched down so many that she was ill. She tried an e-cigarette and hasn't touched a real one since, which is just as well given my problems, and the fact that they're £8 a packet now.

They're not ideal, they worry me, but he's mental health had to come first. Her workplace insists that they be used outside as to do otherwise is unprofessional. The brand she uses is apparently the brand the NHS recommends as a way to ease off traditional cigarettes, and it looks like forthcoming legislation is about to declare them as pharmaceutical devices that can only be purchased at the chemists, which should mean tighter safety regulations.

I'm not over the moon that her nicotine addiction is active again, but as patches did nothing but cause mental disturbances (including night terrors), lozenges contain so much salt that her face was bloody purple, and she can't very well chew gum without teeth**, they're the lesser of two evils, and she plans to taper down to the 0mg cartridges eventually, before quitting again.

As for Jenny - hands up who's surprised that Ms "BIG PHARMA MAEKS EBIL BABBY-KILLING TOXINS!!!11" is a) a hypocrite for hawking a known teratogen or b) someone who values money over morals?

*Being dropped to the floor by nurses doesn't count. Apparently they wanted to check to see if I was faking not being able to walk, I know this because that's what they told me. My knee doesn't bend anymore and has been excruciatingly painful ever since, but until I can get out to seek medical help I'm kinda stuck. But on the good side, at least I know it won't buckle under me again, because it's rigid. Thanks nurses!

**Prednisolone made her teeth crumble away to nothing, but it did save her life so it seems ungrateful to complain too much.

"in the case of blu™ e-cigarettes this light is blue, for reasons that escape me."

At a guess, I would say A: Marketing - as Blue LED's seem to be the cool color. And B: less likely to be confused for the real thing. I have seen people turn one of these things on in a place that bans real smoking and then get into an argument as to whether it was a real cigarette or not.

@Narad - try cold-brew coffee (as in, it's brewed with cold water, not simply hot coffee that's been iced down) for something that is WAY less bitter than the regular variety.

My swain introduced me to cold-brew coffee made with a French Press and I was an instant convert. I haven't tried making decaf yet, but I should! (Right after I finish stockpiling my stash o'frozen coffee cubes to put in iced coffee)

@Narad – try cold-brew coffee (as in, it’s brewed with cold water, not simply hot coffee that’s been iced down) for something that is WAY less bitter than the regular variety.

No, I was saying that decaf lacked the bitter edge contributed by caffeine. I've had the cold brew, and that does suit me just fine, or at least it did when I went through a gallon of it in a 40-hour drive from Chicago to Seattle.

I use coldbrew tea sometimes. It was very useful in a hotel so I didn't need to make microwaved tea ( which I object to for some arcane reason I don't entirely comprehend. But I do) and easy to carrt around and put in water bottles.
If you let it stand it becomes amazingly strong.

* elburto:
I'm truly sorry to hear about your and OME's hard times. I hope that things are contimuig to improve in many ways.

From The Chemist and Druggist, the UK pharmacy trade magazine (behind a registration wall, but other articles about this available)

Growing concerns over the safety of e-cigarettes and the widely varying nicotine content had prompted the decision to regulate the products – probably as GSL medicines – within three years, the MHRA revealed.

The plans will impose quality standards, advertising restrictions and possible age restrictions on all nicotine-containing products, to coincide with a revision of the Europe-wide tobacco products directive, which is expected to come into force in 2016.

The worst part about e-cigs are the proponents. I suspect they use a lot of viral marketing strategies and "grass-roots" advocacy, funded by industry.

I tangled a while back with one such association over my video on e-cigarettes, basically coming to similar conclusions as Orac. I can't recall the name of the group, but all of them managed to show up on the same day that a link to my video was posted on one of their forums. All of them accused me of wanting to kill smokers. All of them quoted the same statistics about the success rate of stop-smoking programs. I suspect it's just a matter of time before they show up here and SPAM the comments.

After all the times the finger has been pointed at me, it was the first time I have ever accused someone else of shilling.

Also, there's a surprising lack of understanding by these groups of how nicotine affects the body. It ain't sunshine and roses. You stimulate any receptor for long enough at high enough doses, and something will go pear-shaped.

One more note:
My biggest concern is that these products will become more popular among young people. The marketing is all slanted VERY young, including juice with fruit flavors, young models shown in ads, and the places they advertise (social media sites). The medical community has made great strides in communicating the risks of smoking... e-cigarettes could potentially reverse some of that progress by muddying the water.

It's clear that the goal is to move everyone to 1. If you consider people going from 1 to 2 (nonsmoker to ecigs), that's an increase in risk, which has to be weighed against the effectiveness of 3 to 2 risk reductions.

That is, the e-cig people only talk about the risk reduction gains, but not the losses.

I can’t recall the name of the group, but all of them managed to show up on the same day that a link to my video was posted on one of their forums. All of them accused me of wanting to kill smokers. All of them quoted the same statistics about the success rate of stop-smoking programs. I suspect it’s just a matter of time before they show up here and SPAM the comments.

Oh, I crossposted a slightly less "insolent" version of this post at my not-so-super-secret other blog. (What can I say? When I've written something this long and in-depth, I want as many people as possible to see it. Besides, a magnum opus like this takes more time to write than I should be dedicating to blogging; so when I'm done with it I don't have time to do a special post for this blog.) A couple of e-cigarette boosters have already shown up there. I know it's only a matter of time before they show up here. Just look at Matt Carey's post that I linked to above. He's driven the comment count over there up to over 150.

Oh, yes, I expect an invasion, much the same way as the anti-GMO activists did on my GMO posts. It's only a matter of time.

That is a Pavlovian pairing procedure that bears a resemblance to the technique demonstrated in A Clockwork Orange. There is very little evidence that it is effective for anything (e.g., smoking, drinking, homosexuality - a particularly horrible application). Such responses are often due to operant learning (or involve genetic predispositions) and Pavlovian techniques are generally ineffective because contingencies (phylogenic or operant) drive the boat with such behavior. And yes, it is an attempt to use aversive conditioning.

I'm a 61-year old lifelong smoker who just switched to e-cigarettes a week ago. I find them substantially superior to unfiltered Camels in nearly every way. They're far cheaper. They eliminate the associated waste of smoke, ashes and butts. My incisors are no longer stained black. I'm breathing better, I think. Suddenly there's room in my shirt pocket.

I have definitely stopped "smoking" (the two cigarettes I've tried since, for the sake of comparison, were repulsive) but I certainly haven't given up nicotine; for all I know "vaping" has upped my intake.

There doesn't seem to be much discussion of carbon monoxide. If it's absent from the vapor, since combustion isn't involved, that would be an unambiguous benefit. Hemoglobin takes up and retains monoxide, so that smokers wind up with a higher than average concentration of red blood cells in order to maintain oxygen throughput (or so I've heard).

I went back to the comments of my older e-cig data, and it was CASAA that showed up in force. I had a long (but polite) exchange with Kristin Noll-Marsh about why the industry was fighting regulation so hard, given that it would protect consumers from manufacturing impurities, especially in products imported from countries without US standards of QC. I suspect the driving force for the fight against regulation is Chinese company Ruyan, the giant in the e-cig world.

The next day, I had a sudden inrush of traffic critical of my content. Given that the vid had already been up for 6 months, I thought this was odd. Then I noticed they were all parroting similar statistics... a Google search revealed the cut and paste source on CASAA's website. I don't know if it was a team or a single person with multiple accounts.

What strikes me about CASAA is that the board is stacked with power players: lawyers, smokeless tobacco lobbyists and web marketing experts. Not a random assortment of Americans, but exactly what a company would seek out as a PR front.

E-cigs probably do represent a reasonable risk reduction strategy... which makes it all the more suspect that they are putting so much effort into opposing regulation and Internet marketing using these tactics. It's a shame they don't just put those funds towards some proper trials and basic science.

I have no scientific evidence, merely my own anecdote (not data, I know, I know). If you will permit:

I gave up a 20-year cigarette habit with the help of e-cigarettes. I had previously tried Zyban (ineffective), Champix (made me violently nauseated), and patches (gave me horrible nightmares and left nasty patch-shaped rashes on my skin.) With my ecig I went from 20 cigarettes a day to zero in 72 hours. My perma-cough and indigestion have cleared up.

The best thing about e-cigs is that I can dose myself precisely as needed. Whereas with a cigarette, you have to smoke the whole thing, with an ecig I can take one puff and be done. I have lowered the strength of the E-liquid I use from 24mg to 18mg to 15mg and eventually plan to cut down to zero and then quit vaping.

Yes, e-liquids come in different flavors, and no, this is not evidence they are marketing to kids (I like tobacco, blueberry, and cinnamon roll flavors best.)

By the way, I wouldn't buy Jenny's brand of e-cig--they're wretched. Tiny batteries that last about an hour and awful flavors.

As I said, this is the furthest thing from proof, but anything that gets you off the smokes is a good thing. I will stop proselytizing but if anyone wants to know more please get in touch.

What strikes me about CASAA is that the board is stacked with power players: lawyers, smokeless tobacco lobbyists and web marketing experts. Not a random assortment of Americans, but exactly what a company would seek out as a PR front.

Well, that explains a lot, at least as far as the dubious "study" that wasn't anything more than a review article not published in a peer-reviewed journal. I wonder when they'll show. up. I also expect ACSH to respond soon. They have responded before when I've criticized them.

I want to add one perspective that I have not heard discussed. When my mom was put under hospice care with very advanced lung cancer (with a prognosis of two months to live), she was advised to use oxygen continuously. However, with her rapidly declining mental state and two-pack-a-day smoking habit, quitting smoking would have been practically impossible, and in my opinion utterly cruel to someone suffering with a terminal illness on top of a mental illness that already makes quitting smoking more difficult than for the average person.

E-cigarettes provided a way around that problem. Since they are small vaporizers that do not use flame, they should not pose a risk around oxygen, and they also do not pose a fire risk from a cigarette dropped on bedding or clothing.

I'm skeptical of E-cigs mainly because of the threat that they would addict new people to tobacco and serve as a gateway to smoked tobacco products. But at the same time I am very grateful that such an option existed for the duration of my mother's hospice care, to provide her accustomed nicotine in a tactilely comforting way. Having seen her attempt to quit smoking before, I am certain that nicotine withdrawal would have added a nightmarish element to what is already the most difficult fate a person must endure.

As for e-cigarettes being an aid to stop smoking, it is noteworthy that the blu e-cig FAQ contains the following Quack Miranda Warning (according to Matt Carey)::

"blu should not be used as a quit smoking device as it has not been approved by the FDA as a cessation device. blu eCigs are not a smoking cessation product and have not been evaluated by the Food and Drug Administration, nor are they intended to treat, prevent or cure any disease or condition."

Of course, e-cig makers are hoping that enough hints can be dropped about alleged stop-smoking benefits to get around FDA regulations on new drugs.

I am against allowing these things to be used in confined spaces (in particular, on commercial flights) until it can be demonstrated that there is no significant exposure to nicotine vapor from an e-puffer sitting near you.

@ c0nc9rdance:
The attempts at avoiding regulation make me wonder if there is a business niche in developing an e-cig and getting it reviewed, regulated, and approved as a cessation device so that it can be marketed on its safety and quality rather than appeals to sexiness.

I watched that commercial for blu without any sound on and it's just kind of nauseating. If there was ever an curiosity in me about e-cigs that just kind if quashed it.

•Nicotine taken in any form passes into breast milk and is harmful to the nursing infant. However, for women who are unable to give up smoking without a smoking cessation aid, NRT may deliver less nicotine (and none of the other potentially disease-causing agents) than would be obtained from cigarettes. It is also less hazardous than the second-hand smoke that the infant would be exposed to if the mother continued to smoke.
•However, if possible, nicotine patches should be avoided during breastfeeding because they provide a continuous stream of nicotine into the breast milk. It is better to use intermittent forms such as gum, lozenges, microtabs, inhalators or nasal sprays, because these can be more easily adjusted around breastfeeding times to minimise the amount of nicotine that the infant is exposed to via the breast milk. Seek advice from your doctor or pharmacist

The caffeine you enjoy in your coffee most likely has the same effect on your body as the nicotine-only in e-cigs!!!

Not that I doubt you, but do you have a source for that? Caffeine and nicotine (despite rhyming) are different chemicals with substantially different structures and chemical compositions. I would thing that each affects the body differently. However, if you have data I would be willing to reconsider.

Second of all, if it weren't for e-cigs, I would have never been able to put tobacco cigarettes down. Yes, you still get the nicotine, but you don't get the 4000+ chemicals involved in a "real" cigarette, much less the carcinogens. Yes, there are problems associated with nicotine, we all know that, however, it is certainly much safer than smoking a burning wad of tobacco. I'm slowly weaning myself down from a nicotine level that I was smoking at (24 mg), in an effort to eventually reach zero nicotine.

Thirdly, some of those side effects from those vaping e-cigs tend to be from the carriers of the flavor - propylene glycol and vegetable glycerine. Both are desiccants, which means they will dehydrate you, and you need to keep up your fluid intake. BTW, both PG and VG are considered safe by the FDA, and are contained in many things we already use/eat. The coughing could be from all the crap coming out of their lungs from eliminating the tobacco inhalation, with the smoke/tar, everyone who switches from tobacco to vaping gets it for a short time.

Almost all of the people I "run in to" on vaping forums have completely given up tobacco. Why? That was their purpose when starting the e-cigs. Smoke, tar, etc., are all powerful reasons to quit sucking on burning tobacco leaves. And most of them are weaning their way down to zero nicotine.

I'm guessing in the studies you quoted, they used the faux cigarette types, and not the other type of e-cigarettes out there - the ones that come with a battery, and a tank of some sort, that look nothing like a cigarette. Frankly? Those work best.

And no, there is nothing sexy about smoking (I smoked for 24 years), but I certainly don't feel sexy when I when I take a pull off my e-cig equipment.

AND the FDA is currently getting ready to hold hearings to try to get the authority to expand their oversight of tobacco products to include any and all type of e-cigs. They are also trying to use that authority to get flavored e-liquid taken off the market, or plan to once they get the approval, just as they are now starting to work on getting methol cigarettes off the market. What keeps me from going back to regular tobacco, even though I KNOW this is healthier? Flavor. The e-cigs generally taste better than cigarettes, and that's how the keep you from going back to the tobacco sticks, or analogs. I've heard more than a few people say if the FDA manages to ban flavor in e-cigarette juice, they'll either make their own (it's supposed to be easy to make), or they'll end up going back on the tobacco cigarettes.

Nicotine DOES act as a stimulant, similar to caffeine, although there are more side effects.

Tina, your comment begins byadvertising a 'study' which has already featured in Orac's original post, where he dismisses it as simply a “technical report” posted at the Drexel website and touted by press release. So here you are, spamming the very same press release.

Can you see why people might decide that you are spamming on this post without bothering to read it, and that you are just another low-life bad-faith shill from whom no truth is to be expected? And why they might decide that CASAA is a dishonest hive of lying lobbyists whose claims are likely to be the opposite of the truth, if they must resort to hiring shills such as yourself?

If Tina had bothered to read the thread before adding her spam, she would have noticed comments such as #43 from c0nc0rdance... which in effect are hypothesis-testing predictions. If CASAA is a lobby group devoted to promoting junk science, whose involvement in a study is enough to write it off as bullsh1t, then new commenters will soon turn up at RI to spam that CASAA study.
And here is Tina! Hypothesis confirmed!

I went back to the comments of my older e-cig data, and it was CASAA that showed up in force. I had a long (but polite) exchange with Kristin Noll-Marsh about why the industry was fighting regulation so hard, given that it would protect consumers from manufacturing impurities, especially in products imported from countries without US standards of QC. I suspect the driving force for the fight against regulation is Chinese company Ruyan, the giant in the e-cig world.

The next day, I had a sudden inrush of traffic critical of my content. Given that the vid had already been up for 6 months, I thought this was odd. Then I noticed they were all parroting similar statistics… a Google search revealed the cut and paste source on CASAA’s website. I don’t know if it was a team or a single person with multiple accounts.

The inrush has begun at my not-so-super-secret other blog. Bill Godshall of Smokefree Pennsylvania has shown up in the comments of that version of the post, and hilarity has ensued. It's obvious from his comments and the studies he cites that he didn't bother to read the post in depth. He probably just noted the title and the mention of Jenny McCarthy at the beginning and then did some cut'n'paste "document dumping."

Jenny McCarthy smoked while she was pregnant? [...] Apparently, yes. She wrote about it at one time.

Dear FSM. What an enormous hypocrite. Babbling about on-off administration of tiny amounts of chemicals while advertising a device that is designed to administer a potent insecticide directly into the bloodstream (or near as dammit) is one thing. Blaming vaccines for her son's developmental disorder when she regularly delivered a cocktail of toxic chemicals into him as a developing fetus, at the most vulnerable period of his whole life? Those bioidentical hormones must have frazzled her brain.
Or was that Suzanne Somers? Is there any discernible difference I can use to stop me from getting them confused? Does it matter?

@Narad:
I love my coffee, and am a sort of reverse coffee snob. I buy whole beans at Fairway, grind them by hand in a cast iron grinder, and drizzle boiling water over them by hand in a Melitta filter cone. My father taught me to drink it black as he did in the Navy; I quickly saw that good coffee doesn't need milk and sugar, and bad coffee isn't much helped by it. I also love caffeine in it's many forms and find it helps some of my medical conditions as well. However....
There are times that call for a hot drink but caffeine is definitely contraindicated, such as at 3 AM when I get up to read because I can't sleep. Decaf coffee is then my nondrug of choice. Decaf tea is pointless. Herb teas are sometimes soothing but choosing one at the market is overwhelming, just too many competing ones. I find that decaf Taster's Choice or Nescafe freeze-dried instant are both tolerable and undemanding on the appreciation faculties. I do agree that Sanka is an evil, foul concoction straight from the Devil's prostate, and remember with horror that at Harlem Hospital the midnight housestaff coffee lounge was stocked with a cheap Sanka knockoff as the only coffee. Even Satan wouldn't be so cruel as to make anyone drink that, although the urn coffee in HHC hospitals had a taste and smell that could only have come straight from the pathology department.
All that said, does anyone know anyplace in the English-speaking or -mangling world where Gunung Blau beans can be bought?

So the e-cigs are still giving you an unknown quantity of an addictive insecticide? I guess the only way you could say that they are actually 'safer' than traditional tobacco products is that you (probably) can't burn the house down with them.

@JustaTech - in all fairness, I'm suspect the difference in tars and various other combustion compounds (e.g. carbon monoxide) might mean that e-cigs are somewhat safer. How much safer depends on the actual studies, naturally.

It is true that e-cigarettes could stand a bit more research. But, atleast with e-cigs, you eliminate second hand smoking and the 'cigarette stink.' As for Jenny McCarthy, let's not talk about her at all.

So we can assume you sent her a personal notice to not be involved in the advertizing program for that product.

And shouldn't we just tell kids and others to not purposely inhale toxins in their lungs? Because what are e-cigs? They are just another way to inhale toxins like nicotine or something else directly to the lungs. That can't be good.

So do your research. Make sure it is honest. But definitely do not advertize that particular nicotine delivery product by anyone.

And shouldn’t we just tell kids and others to not purposely inhale toxins in their lungs? Because what are e-cigs? They are just another way to inhale toxins like nicotine or something else directly to the lungs. That can’t be good.

I doubt if Mr. John Hallal can be honest or objective about this subject. He owns a company called Aviator Club that sells e-cigarettes.

He's posted several glowing articles and comments shilling for e-cigs on various blogs and self-publishing vanity websites.

So it seems that the product Jenny McCarthy shills for is Mr. Hallal's competition.

I had considered changing my 'nym a few times over the
past year but was encouraged by a couple others here to keep it, in the hope newcomers might get curious and look up who MS was and discover his shenanigans that helped put Burzynski "on the map."

You might have inspired me to finally make the change, however. I rarely post anymore so it's almost a moot point, but I do have a new 'nym picked out and will use it the next time I post. I'll make sure Orac knows it's me, and not an attempt to sockpuppet.

Damn you--you made me look at whale.to! Now I have to wash my eyes out with soap.

Is HCN contained in laetrile/apricot pits/"B-17"? Is it the same kind of cyanide?

Maybe Mr. Hallal can recruit another celebrity with no credibility to shill for his e-cigs. On his blog he posted photos of some famous people using e-cigs, including Lindsay Lohan and Courtney Love. Either one would give JM a run for her money in the loony department.

As a longtime fan of Dave Grohl and the Foo Fighters, I have decided to change my user name to Woo Fighter.

You do realize, don't you, that the Foo Fighters have supported HIV/AIDS denialism? I don't know if they still are, but their support for Christine Maggiore's group (obviously before she died of AIDS) turned me off on them along time ago:

Why do you have to smoke the whole thing with a cigarette, Sasha? What exactly prevents anyone from taking one puff and then extinguishing the cigarette?

It's pretty wasteful, depending on the size of the coal. One really needs sand to do this effectively, and then one has to immediately remove the extinguished coal and blow air back through the square* to prevent it from becoming increasingly foul.

I suppose one could carry around scissors and snip off the lit end of a cigarette. Of course, one should really compare the price of a puff of an e-cigarette to the cost of a single cigarette used for just a puff or two to see if it's worthwhile.

I personally am willing to concede that e-cigarettes and their ilk are easier for people to use in different "doses" than one would get from actual tobacco. I'm also willing to concede that people who use e-cigarettes don't make my eyes water or clothes stink near as much as actual tobacco users.

Whether it's safer for the person using the product still requires study.

Of course, one should really compare the price of a puff of an e-cigarette to the cost of a single cigarette used for just a puff or two to see if it’s worthwhile.

My understanding is that they're cheaper under any circumstances. This is certainly what a friend reported, although she seems to have switched back to the regular ones. I believe it involves buying the cartridges in bulk.

Whether it’s safer for the person using the product still requires study.

Without question. It's somewhat difficult to imagine it being worse, but one never knows.

@JGC

i agree it would be wasteful, but your ultimate goal is to stop using the damn things after all.

I sorely doubt that this is the motivation of the bulk of consumers of electronic cigarettes.

I’d consider making your vice more costly to maintain an additional incentive to acheive that end.

Where I live, this simply amounts to extremely regressive taxation (I started seeing bootlegging of menthols back when prices were only $8 a pack). It may be effective at preventing the habit from getting entrenched in the first place, but one might argue that raising the legal age could have about as much effect.

Well written article. I've read a lot of the available research out there, which is, unfortunately, quite thin. The way I look at e-cigs is, it would be very stupid for a nonsmoker to start using an e-cig for any reason. But it would be stupid for a current smoker not to try using them if not to quit, then at least to reduce the likely harm.

I switched to an e-cig after six years or so of heavy smoking and never went back. For what it's worth, I'm not a big fan of Blu, particularly since the company's acquisition by a tobacco conglomerate.

You might want to do a little research about e-cigarettes before making such uninformed, scare-mongering statements. By all means take Ms McCarthy to task for her anti vac nonsense, but when she is promoting something that as an alternative to tobacco cigarettes is clearly less harmful, that is to be lauded, not pilloried. There is no evidence that ecig use by teens or anyone will “ruin their hearts, give them cancer, and shorten their lives.” Do some research before making ignorant statements.

@Rob - given that the exact same substances that Ms. McCarthy complains about in vaccines are in e-Cigs, in larger doses, it shows how much of a hypocrite she is to endorse one product, while vilifying the other.....

"Clearly" is an overstatement since the proper studies haven't been done and many of them, on long term effects, can't be done yet. However, considering that the choice in most cases is between cigarettes (nicotine+kitchen sink) and e-cigs (just nicotine), it does seem very likely that the one without the kitchen sink will turn out to have the preferable risk profile.

They are still a delivery device for an addictive drug. It's a drug we've decided, socially, is acceptable for public use for whatever reason, so that's really neither here nor there. Purchase restrictions should be the same as for actual tobacco; advertising likely to target teens should be prohibited.

Ideally, we wouldn't have anyone doing either, but that's not the real world.

And in the real world, ecigs are probably safer for the smoker than real tobacco due to the lack of the tar load, etc. They are also probably safer in terms of secondhand exposure, although I still would prefer their use be restricted in confined areas. They are certainly safer in terms of thirdhand exposure (such as absorption and re-emission of tobacco products from furniture, carpets, etc.); while a scientific study to confirm that would be nice, I'm willing to trust the "smell test" here, literally. Additionally, ecigs do not have the fire risk of actually using burning plant matter for your drug habit, and do not have the environmental litter load of discarded butts.

Clearly, some safety regulation to ensure the ecigs perform in a reliable manner (consistent dosing, etc.) and proper labeling are desirable, but the benefits of replacing traditional tobacco products with vaporization systems seem considerable even if the actual health benefits gain to the smoker is marginal.

Antaeus Feldspar - Some pioneering freethinkers won't bother waiting for the evidence about ecigs. They just make a decision based on what they know so far - rationalising that its probably less harmful than tobacco and hasn't yet caused anyone serious side effects. The unscientific fools.

Jim - It's not irrational, or unscientific, or foolish, to think that e-cigarettes might be less harmful than regular cigarettes - so kindly don't put that straw man in my mouth.

What I was responding to was someone saying they are "clearly less harmful". The evidence is simply not there for that level of certainty. If someone wants to make a decision based on what we know so far, that's fine for them. That doesn't give them the right to spread misinformation.

Smoking isn't just about the Nicotine,if that was the case Nicotine patches and gum would work 99% of the time.It is about the actions/habit associated with it. The throat hit,the blowing of smoke,the time of relaxing while smoking,etc.
I went from being addicted to cigs then addicted to ecigs. Once I got addicted to Ecigs I NEVER wanted another cigarette in fact I got to hate them since I could smell what non smokers could smell.I started smoking at age 13,I remember growing up I would get so short winded when doing any activity.After not having a cigarette for 4 years I run 3 miles a day with ease.I smoked for 35 years btw. Once I was addicted to ecigs I used it for half a year then cut down my Nicotine lvls.I did this until I was at 0% Nicotine. I still enjoy vaping but if I can't no biggie. I enjoy a lot of things in life anytime I can do them like sex but if I can't I will be ok.

All one has to do is research and they will find many,many testomonials of people that changing over to Ecigs has changed their health completely.It did for me. I had a physical last week and the Doctor said my Lungs sounded beautiful,I was healthy and had a A+ checkup. 6 years ago when I smoked I had high blood pressure and chronic Sinus problems,I could walk up a set of stairs without getting short winded. After years of not smoking but vaping I have not been sick 1 day,my blood pressure is normal and I run three miles a day. My mother is the same way,she has COPD and used to cough so much it would make her cry. She started ecigs and 4 years later she doesn't cough a bit. I will say less harmful than regular cigarettes because they have changed many lives.

From all the research I have done so far it seems obvious to me that e cigs are less dangerous than smoking tobacco cigs but since there really isn't a proven long-term study yet I guess it isn't a good idea to say anything is for sure. I have been getting ready to try and switch myself, I got a few friends that seem to be happy with their new vapor toys. But I have talked to a few others that said it made them cough even more. One guy at my local coffee shop said he had to stop using it. I wonder if he had a bad brand though or bad e-liquid, who knows.

Electric cigarettes share some issues with there classic counterparts, such as appearance, feel and taste of any normal e cigarette. But your differences usually are substantial in this the "safe cigarette" receives it's name given it produces none on the negative issues with traditional smoking cigarettes like tar, ignition (heat), nearly 4000 sorts of chemical additives that often result in respiratory and cardiac technique diseases, neither the carcinogenic effects of classic cigarettes.

From the time that the Physician General motivated that using tobacco is hazardous to your health, cigarette firms have wanted ways to lessen tar and nicotine ranges, in efforts to produce a more risk-free smoking knowledge. Nothing, even so, has actually come near to the electronic e cigarette.
This ground-breaking new smoking cigarettes alternative, not just simulates cigarette but in addition the temperature related to dragging off perhaps the most common cigarette (50-60 certifications Celsius), thus preparing the internal habit with out adding your hazardous substances that are fitted with proven to be able to cause malignant, including carbon dioxide monoxide, nitrogen dioxide, hydrocyanic chemical p, acrolein, arsenic, guide and hydragyrum.

Smokeless tobacco were first viewed with trepidation but an increasing number of have grow to be embraced with the public along with the Medical Association. E-Cigarettes are now manufactured by a number of different companies through the US and China and are all around across the united states and The european union, even the the most ardent skeptics have grown believers once they try your electronic e cigarette.

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